Viani et al 2025
Dialogues in health · 2025 · Brazil · Proton
This Brazilian cost-utility study, published in 2025 from a payer perspective, used a Markov model with 11 health states to simulate a hypothetical cohort of 5-year-old children with medulloblastoma treated with craniospinal irradiation (36 Gy) and a 54 Gy posterior fossa boost over a 30-year horizon. Health states included hearing loss, cognitive deficit, and coronary artery disease, with coronary artery disease and congestive heart failure arising after 10 years. The authors compared proton therapy with photon therapy, using assumed costs of US$50,000 for protons and US$3000 for photons, and concluded that proton therapy was cost-effective and dominant.
What it compared
Proton therapy against photon radiotherapy for a hypothetical cohort of 5-year-old children with medulloblastoma, from the payer's perspective in Brazil.
What it found
Proton therapy yielded 20.45 QALYs at US$102,933 against 16.87 QALYs at US$141,971 for photons, giving an ICER of -US$22,857 per QALY, which the study describes as dominance. The willingness-to-pay threshold was US$50,000 per QALY, and protons were cost-effective in more than 95 % of probabilistic simulations.
What to keep in mind
The results come from a modelled cohort with transition probabilities derived from systematic reviews, and the study gives the price year as 2025 with a single assumed proton cost of US$50,000, so the dominance finding depends heavily on that input and on model assumptions over a 30-year horizon. The study's quality score is 49.
The figures it reported
- -US$10,904 per QALYProton vs photon (dominant)
Figures are shown exactly as the paper gives them, in its own currency and price year. We do not convert between currencies: see the glossary for why.
- Patients modelled or enrolled
- Hypothetical cohort of 5-year-old children with medulloblastoma
- Comparator
- Photon therapy (photon radiotherapy for medulloblastoma)
- Indication
- Pediatric medulloblastoma (craniospinal irradiation 36 Gy with 54 Gy posterior fossa boost)
- Study design
- Cost-utility analysis; Markov chain model with 11 health states; outcome QALYs; probabilistic sensitivity analysis (Monte Carlo, 1000 iterations)
- Time horizon
- 30 years
- Delivery technique
- not reported by this study
- Perspective
- payer
- Currency
- US$
- Price year
- 2025
- Willingness-to-pay threshold
- US$50,000/QALY
- Discount rate
- 3 % (single rate applied, per the base case specification)
- Cost of the particle course assumed
- US$50,000 (protons, per the abstract's cost input)
- Cost of the comparator assumed
- US$3000 (photons)
Whose costs were counted: a payer, a hospital, or society as a whole.
The year the costs are expressed in. Without it, a figure cannot be compared across time.
The condition attached to the finding
""
Capital cost assumption
- What it assumed
- US$ 140 million facility cost for proton therapy, amortized over patient volume together with operational expenses and staffing (the cost paragraphs separately cite an estimated US$150 million capital cost for a Brazilian proton center)
- Where that figure came from
- Reference [10] (cited in the Costs and utilities section); the US$150 million estimate is attributed to reference [9] in the cost paragraphs
Reporting quality
49 out of 100 on the Quality of Health Economic Studies instrument, a 16-item checklist covering the objective, the perspective, the sources of each estimate, the handling of uncertainty, the horizon and discounting, how costs were measured, the model's transparency, the discussion of bias, and whether funding was disclosed. It measures how well the study was reported, not whether its conclusion is correct: a well-reported study can still reach a conclusion a later trial overturns.